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COVID-19 in Maryland Health Care

Two Spoons, a Pair of Gloves and a Family Member: Dental Health in the Time of COVID-19

Photo courtesy of the Maryland State Dental Association.

The COVID-19 pandemic has changed lives for every Marylander, from masking up to go to the grocery store to attending family gatherings and business meetings over Zoom. But it’s also had a huge impact on the way that people seek out routine, preventative healthcare services.

In the pandemic’s earliest days, Gov. Lawrence J. Hogan Jr. (R) signed legislation allowing doctors to meet with their patients via telehealth platforms.

“The Maryland Department of Health, recognizing the importance of oral health to overall health, added teledentistry to that,” Mary Backley, CEO of the Maryland Dental Action Coalition, told Maryland Matters.

Though difficult to imagine in practice, dentists for months now have been using telehealth as a means of triaging patients, giving care recommendations and analyzing whether or not they need to prepare for an in-person evaluation.

“And it keeps patients out of the emergency room,” Backley added, “especially during the phase when the dental services were not available in late spring when COVID really took off.”

With just ordinary household objects, patients are able to have a full dentist office experience from the comfort ― or discomfort ― of their own homes.

“It’s amazing what you can do with two spoons to retract and look in there,” Dr. Charles A. Dorring told Maryland Matters in an August phone interview. “Sometimes the spouse, or the son or daughter that’s very good with a cell phone, they’ll just snap a picture and email it to me.”

He explained the process simply: prior to the appointment, his patients were instructed to have two spoons, a family member and some rubber gloves on-hand in case their mouth needs to be retracted. When they met virtually, Dorring went through their health history and why they called for help ― as though it were a normal appointment ― and, once he finished listening, would ask to see inside their mouth through the patient’s camera.

“I can get back all the way back and visualize the second molar fairly well,” he said.

Dorring told Maryland Matters over the summer that telehealth has been especially helpful for high-risk groups, like the elderly.

“I also serve at nursing homes, so the nursing staff has sent me a picture and let me take a look at that,” he explained.

Dr. Sandra Garbley, whose offices also use teledentistry services, said that while helpful for screening patients, there are barriers to access including stable internet, the ability to download the appropriate apps and teaching technologically challenged patients how to use them.

“That was the barrier there, but at least we had some access to care that didn’t have to bring them in the office,” she said.

Garbley is the senior vice president and chief dental officer for Choptank Community Health, a federally qualified health center serving uninsured patients on a sliding scale, as well as people with Medicare, Medicaid and commercial insurance plans in Caroline, Dorchester and Talbot counties.

Now that her clinics have transitioned back to performing all procedures, Garbley said that clients are “beating down our doors” to come in for their regular appointments.

“I saw the transition of people being hesitant, to then ‘Okay I feel safe because you’ve told me that,’ and now it’s like, ‘When can you get me in?’” she said.

Dorring practices at North Bethesda Dental Associates, which has now fully reopened for all oral health care services, but he’s still using telehealth to see patients in nursing homes or as a method of allowing pre-med or dental students to shadow his practice.

He added that he sees a lot of possibilities in teledentistry, like expanding care to patients in rural areas or even collaborating with other healthcare professionals to offer more comprehensive care. He called the prospect of the latter “kind of exciting.”

“I think dentistry … has its place with physicians, dieticians and physical therapy and all these other health care providers,” Dorring said. “And I think this is just an avenue to help bridge that gap because a lot of times dentists work kind of on our own — do our own little thing.”

“I don’t think it should be that way,” he asserted. “I think we need to engage all the health professions.”

‘Nobody knew what was going on’

For dentists across the state, COVID-19 presented a whole new set of challenges.

“I’ve been practicing dentistry for over 30 years, and only one other time do I ever remember protocols and procedures ― especially regarding infection control ― had changed so significantly and that was during the AIDS and HIV epidemic,” said Garbley.

HIV is a bloodborne pathogen, so Garbley said she really needed to re-evaluate how her clinics would be able to care for patients while combatting an airborne virus.

Choptank Community Health had to inspect the HVAC units at each of its sites to ensure that clean air was flowing through, and once that process was completed needed to look into enhancing the airflow.

“With our facilities director, … an engineer, myself and our dental clinical quality director we reviewed so many different webinars and seminars, watched things, I got on the National Network Oral Health Access websites, the ADA, OSHA, OSAP ― you name it,” Garbley said. “We were trying to just gather information because nobody knew what was going on, right? So we were all trying to figure it out as we went.”

They settled on photocatalytic oxidation machines, which have carbon filters, HEPA filters and release photoions capable of killing the virus if the droplets are small enough.

When patients leave their operatories, staff members let air flow through the room for a minimum of 30 minutes before disinfecting the space, “so we were getting the virus that was in the air taken care of, and then also those droplets,” said Garbley.

But there’s also a human element to preventing the virus’ spread at her clinics.

Like many other dental facilities in the early days of COVID-19, Choptank Community Health’s clinics restricted their services to those in need of urgent and emergency care.

Since the beginning of the pandemic, Garbley said that all dental and medical staff and patients at each of their sites are screened and surveyed.

Patients are interviewed over the phone before being allowed inside. If they’re fit to enter, their temperatures are taken at the door before being taken back to operatories, which Garbley described as “bare bones” ― nothing on any surface short of the tools necessary for the procedure at hand.

When being seen, patients are given a pre-procedural anti-viral rinse and use oral suction devices to lower staff risk of exposure.

Staff members are given N-95 masks, and are fit-tested to ensure that no particles flow through.

Garbley said that Caroline County and other resources did the best that they could to get personal protective equipment to her facilities, but “there’s only so many different brands, shapes, sizes of N-95’s, and, unfortunately, it doesn’t fit everybody.”

“I can tell you right now, it is tough to get PPE. It’s tough to get gowns,” she said. “There’s such a shortage still out there, so even if you can get some you’re not always getting the ones that fit your staff.”

For staff members who couldn’t be appropriately fit-tested, Choptank Community Health applied for a grant to receive powered air-purifying respirators, or PAPRs. These are hood air purifiers that cover the entire head, almost like a space helmet.

“We look like Star Wars, kind of, coming into the room,” Garbley joked.

What about the health department?

State and local health departments with dental clinics have been trying to find ways to reopen their doors safely, too.

“Maintaining proper oral health care is a gateway to overall health and essential in combating many diseases,” Charles Gischlar, Maryland Department of Health spokesman, said in a statement. “During the COVID-19 pandemic, the Maryland Department of Health Office of Oral Health has helped to make sure that dental practices in Maryland were aware of the Center for Disease Control and Prevention guidance during this critical time, as well as made available a comprehensive oral health resource guide that connects individuals to oral health services throughout the state.”

At the pandemic’s start, Montgomery County Health and Human Services’ dental clinics had cut back so much that they saw an average of just two or three patients each day from March to June.

“After installing engineering controls and securing appropriate PPE, we are now averaging around 12 patients a day, and the number continues to grow,” said department spokeswoman Mary Anderson.

The clinic run through Baltimore City Health Department is still running at least 50% below its pre-pandemic capacity, with an average of five patients seen each day. Clinicians are not accepting walk-in appointments and are seeing patients for emergency services.

Harford and Charles counties dental clinics closed at the beginning of the pandemic and didn’t resume services until August.

“We’re slowly ramping up to providing all of our services,” said Charles County Health Officer Dianna E. Abney.

Access Is Expanding For Some Marylanders

The Maryland Dental Action Coalition lobbies for better access to dental care for children and adults on Medicaid.

Dental care is currently not included in Medicare coverage plans.

U.S. Sen. Benjamin L. Cardin (D) introduced legislation in 2019 to expand Medicare to allow its beneficiaries to seek out oral health services, but the state has taken its own action in the meantime.

That same year, the General Assembly unanimously passed legislation establishing an adult dental waiver program.

Sponsored by Sen. Delores G. Kelley (D-Baltimore County), the bill allows dual-eligible Marylanders, or those qualified to receive both Medicare and Medicaid benefits, to access preventative, restorative and diagnostic oral health services.

“There’s about 35,000 adults that are eligible for a dental benefit in Maryland through the pilot program,” said Backley. “And even in the middle of a pandemic, we’ve been able to reach thousands of adults with dental care, which has provided over $2.3 million in dental services.

“It’s a significant step forward.”

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Two Spoons, a Pair of Gloves and a Family Member: Dental Health in the Time of COVID-19